Download as pdf or txt
Download as pdf or txt
You are on page 1of 6

June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499

Case Report

Management of space in the mixed dentition: The use of lip bumper


Ben Mohimd H1, Benyahia H2, Taleb B3, Zaoui F4

1
Dr Hajar Ben Mohimd, Post Graduate Resident in Orthodontic Department, 2Dr Hicham Benyahia, Assistant Professor
in Orthodontic Department, 3Dr Bouchra Taleb, Professor in Oral Surgery Department, 4Dr Fatima Zaoui, Senior
Professor and Head of Orthodontic Department; all are affiliated with Mohammed V University in Rabat, Morocco.

Address for correspondence: Dr. Ben Mohimd Hajar, Department of Orthodontics, Center of Consultation and Dental
Treatments, Faculty of Dentistry, Mohammed V University in Rabat. Allal El Fassi Avenue, Mohammed Jazouli Street -
Al Irfane City - BP 6212 Rabat Institutes. Morocco. E-mail: hajarbenmohimd@gmail.com
……………………………………………………………………………………………………………………………......

Abstract
Management of dental space problems continues to play a substantial role in interceptive orthodontics. In the mixed
dentition, moderate crowding problems can be resolved through preservation of the Leeway space, regaining space or
producing limited expansion. The lip bumper is a functional device that is used successfully to intercept developing
dental and occlusal problems by allowing a proper development of the arch length and width for eruption of the
permanent teeth. A nine-year-old female patient with the chief complaint of delayed eruption and lack of space in the left
mandibular quadrant for the eruption of the entire permanent teeth. She was successfully treated in duration of 9 months
with a lip bumper and expansion therapy.

Keywords: Interceptive orthodontics, Management of space, Crowding, Mixed dentition, Lip-bumper device.
………………………………………………………………………………………………………………………………..

Introduction
Crowding and irregularity remain one of the most The concept behind this appliance is based on the
prevalent components of a malocclusion in dental disruption of the equilibrium surrounding the dentition
patients resolved by orthodontic treatment. It is by keeping the musculature of the lower lip and cheeks
characterized by an insufficient available space in the away from the mandibular teeth, [2] this allows the
arch for the alignment of the entire permanent dentition. lingual forces of the tongue to remain unbalanced,
It can appear at various stages of dentition and can causing forward and lateral expansion of the
cause serious periodontal and occlusal consequences. mandibular dental arch. [3] Additionally, the pressure
Therefore, an early diagnosis is important in order to of the lower lip against the lip bumper during
establish an effective interceptive approach [1]. A swallowing is transmitted directly to the lower molars.
variety of treatment modalities have been described to This pressure permits the distalization and distal tipping
gain space in mixed dentition and help to avoid the need of the molars leading to arch length increasing [4] [5].
for subsequent extractions. One of these methods is the
lip bumper. It’s a functional device made of .045 inch This mode of action not only increases arch dimensions,
stainless steel wire often covered anteriorly with a but also promotes the adaptation of soft tissues (lips and
plastic or acrylic shield. The wire is fixed to the first cheeks) to the mandibular expansion, thus providing
molars bands with a distance of two to three millimeters better long-term stability unlike conventional expansion
away from the incisors and two millimeters away from techniques [6] [7] [8].
the premolars and has adjustment loops located just
mesial to these tubes [2]. The lip bumper can resolve The lip bumper can be used in both the maxillary and
arch space deficiency either by maintaining the leeway mandibular arch. However, maxillary appliances have
space at the end of the mixed dentition or by developing been less frequently used. [9] In fact, R. Hasler and B.
the lower arch. Ingervall [10] reported less effect on the anterior-
Manuscript received: 26th March 2016
pos3erior position of the first molars in maxillary dental
Reviewed: 10th April 2016 arch compared to the mandibular, which was explained
Author Corrected; 24th April 2016
Accepted for Publication: 13th May 2016 by the fact that the upper lip is weaker than the lower

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 440 | P a g e
June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

and less likely to generate enough force on the The lip bumper has been indicated in the mixed
appliance unless rigorous muscle exercises are dentition to maintain (molar anchor) or increase arch
prescribed and followed. The mean pressure at rest length and perimeter, through labial incisors
from the lower lip on the lower incisors amounts to 9- proclination and molars distalisation, [15] and to
12g/cm2against 2-5g/cm2 from the upper lip on upper enhance incisor arch form position, when the lower
incisors [11] [12] [13]. incisors are lingually positioned (related to hypertonic
lips); but it can also be used in lip habits breaking and
Regarding the position of the lip bumper in relation to neuro-muscular conditioning. [16].
the incisor crowns, it can be positioned at different
levels. Nevertheless, Hodge et al. [14] measured forces The Present case report reveals the treatment outcome
produced by lip bumpers placed in different positions of a patient with insufficient space for the eruption of
and concluded that more force is produced when the permanent teeth due to the mesial drift of the left molar
wire lip bumper is placed four millimeters anterior to who was treated using the lip bumper device.
the incisors and at a more gingival position.

Case Report
A 9-year-old female patient referred from Oral Surgery Department, to Orthodontics department located in the Center of
Consultation and Dental Treatments (CCDT), Mohammed V University Rabat, Morocco.The chief complaint was
delayed eruption and lack of space in the left mandibular quadrant, where deciduous teeth extraction (73, 74 and 75) was
made months ago after the decompression of a dentigerous cyst.

Intraoral examination shows a passive space maintainer “lingual arch” which was pointless in this case given that the 36
already moved mesially (loss of anchorage) leading to a slight class III molar relationship. Early extractions of deciduous
teeth has led to spaces loss, midline shift, and bi-retrusion of upper and lower incisors causing important overbite, which
can adversely affect mandibular and facial growth [Figure 1].

Figure 1 a-e: Pre-treatment intra-oral photographs

The panoramic radiograph revealed signs of maxillary canines’ retention, and the mesial displacement of the mandibular
left first molar leading to delayed eruption and retention of canine and premolars [Figure 2]. Cephalometric examination
reveals skeletal Class I malocclusion with hyperdivergent facial pattern tendency hence the importance of early
interception [Figure 3] [Table1].

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 441 | P a g e
June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

Figure 2: Panoramic radiograph showed mesial drift of the left first molar and canine’s retention

Table 1: pre-treatment cephalometric values.

Value * Pre-treatment

SNA 80°

SNB 76°

ANB 4°

AoBo 4mm

UI-NA angle 17°

UI-NA distance 3mm

LI-NB angle 18°

LI-NBdistance 4mm

GoGnSn 38°

PogtoNB 1,25mm

Figure 3: profile teleradiograph

*SNA = Sella–nasion–A point angle; SNB = Sella–nasion–B point angle; ANB = A point, nasion, B point angle;
GoGnSn = Gognion- Gnathion (mandibular plan)–Sella–nasion; UI-NA = upper incisor nasion-A point angle and
distance; LI-NB= lower incisor–nasion-B point angle and distance; PogtoNB = chin prominence – nasion- B point
distance

Treatment objective was at first, to regain mandibular space for eruption of the delayed teeth with the use of a lip bumper
that will help to upright mandibular molar and correct overbite by tipping labially the lower incisors [Figure 4].
Secondly, to expand the maxilla and enhance arch form by setting orthodontic appliance which would be propitious to
the eruption of canines and the harmonization of facial growth [Figure 5].

After 9 months of bumper wear, the device provided a sufficient space for the harmonious eruption of the permanent
teeth [Figure 4]. Then the orthodontic appliance corrected maxillary arch form setting a class I occlusion relationship
awaiting canines’ eruption [Figure 5].

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 442 | P a g e
June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

a: lip bumper in place b: After 3 months

c: After 6 months d: After 9 months


Figure 4: Evolution of the case after lip bumper wear

Figure-5a and 5b: Post-interceptive treatment and orthodontic monitoring of maxillary canines eruption

Discussion
Orthodontists have always been faced with the problem [1] Any increase in arch length generally reflects both
of straightening crowded teeth. A variety of interceptive distal movement of the molars and labial movement of
treatment modalities have been advocated in the mixed the incisors. [17]. In our case, the use of the lip bumper
dentition to reduce this crowding, some of which has allowed at first, the restoration of the space that has
include: tooth extraction, expansion, interproximal been lost through mesial drift of the molar and
enamel reduction, flaring incisors and uprighting molars secondly, the anteroposterior and transverse expansion
[2]. of the lower arch to ensure the harmonious
accommodation of the erupting teeth.
The lip bumper is an effective appliance which allows
the management of a mild to moderate crowding Several studies were performed to determine the effects
(<5mm) by maintaining and/or increasing arch length. of the lip bumper therapy on mandibular arch

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 443 | P a g e
June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

dimensions and to quantify experimental variations. prevent unnecessary loss in arch length by either
The effects were discussed under three headings: molar maintaining and / or increasing arch dimensions.
distalisation, arch width and incisor proclination.
In this case report, the use of the lip bumper did ensure
The magnitude and consistency, with which this effect the gain of space through the distal movement of the
has been reported, as well as the sources of arch length molarsand the incisors. This gain of space allowed on
increases, vary among observers. one hand a harmonious development of permanent teeth
and on the other hand to eliminate the need for
Subtelny and Sakuda [4] reported in a study of twenty- subsequent extraction during permanent dentition.
five cases, a distal molar movement in twenty-two. In
Funding: Nil, Conflict of interest: Nil
their opinion, the use of the lip bumper in the lower
Permission from IRB: Yes
arch is synonymous with that of a headgear appliance in
the upper arch.
References
Osborn et al. [15] also quantified several dimensional 1. Ngan P, Alkire RG, Fields H Jr. Management of
changes that occur during the use of the lip bumper. In space problems in the primary and mixed dentitions. J
their study of 32 patients in the late mixed and earlier Am Dent Assoc. 1999 Sep;130(9):1330-9.
permanent dentitions, they noticed that, an average arch
circumference increased by 4.1 mm and the arch width 2. Murphy CC, Magness WB, English JD, Frazier-
by 2 mm at the canines, 2.5 mm at the first premolars, Bowers SA, Salas AM. A longitudinal study of
2.4 mm at the second premolars, and 2 mm at the first incremental expansion using a mandibular lip bumper.
molars. They also reported an increase in the arch Angle Orthod. 2003 Aug;73(4):396-400.
length of 1.2 mm.
3. Bjerregaard J, Bundgaard AM, Melsen B. The effect
Most of the studies of the lip bumper effects in the of the mandibular lip bumper and maxillary bite plate
lower arch showed that the increase of arch perimeter is on tooth movement, occlusion and space conditions in
more related to an increase in arch width rather to arch the lower dental arch. Eur J Orthod. 1980;2(4):257-65.
length. [15][18][19] [20].
4. Subtelny JD, Sakuda M. Muscle function, oral
In a recent study; where dental casts as well as lateral malformation, and growth changes. Am J Orthod. 1966
and tomographic radiographics were used to determine Jul;52(7):495-517.
the effect of six months of continuous lip bumper
therapy on patients with mild to moderate crowding, 5. Celentano G, Longobardi A, Cannavale R, Perillo L.
Davidovitch and al. [6] reported more effect on the Mandibular lip bumper for molar torque control. Prog
molar compared with that remarked with conventional Orthod. 2011;12(1):90-2. doi: 10.1016/j.pio.2011. 02.
cephalometry. In fact, they demonstrated that besides 009. Epub 2011 Mar 29.
the passive increase in the transverse dimension, arch
length, arch perimeter, and incisor proclination, 6. Davidovitch M, McInnis D, Lindauer SJ. The effects
mandibular molars tip distally 3.4° and distalize 0.61 of lip bumper therapy in the mixed dentition. Am J
mm which allowed the resolution of an average of four Orthod Dentofacial Orthop. 1997 Jan;111(1):52-8.
millimeters of crowding more than the control group.
7. Shellhart WC, Moawad MI, Matheny J, Paterson RL,
Conclusion Hicks EP. A prospective study of lip adaptation during
six months of simulated mandibular dental arch
The lip bumper is an effective functional appliance that
expansion. Angle Orthod. 1997; 67(1):47-54.
is used successfully to intercept developing dental and
occlusal problems [16] and as an adjunct to orthodontic
8. Hodge JJ, Nanda RS, Ghosh J, Smith D. Forces
therapy.
produced by lip bumpers on mandibular molars. Am J
Orthod Dentofacial Orthop. 1997 Jun;111(6):613-22.
In selected patients with crowded lower arches, the use
of the lip bumper, properly timed and in conjunction
9. Denholtz M. A method of harnessing lip pressure to
with an accurate diagnosis and complete records, can
move teeth. J Am Soc Study Orthod 1:16-35,1963.

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 444 | P a g e
June, 2016/ Vol 3/ Issue 6 ISSN 2349-5499
Case Report

10. Häsler R, Ingervall B. The effect of a maxillary lip 16. Ghafari J. A lip-activated appliance in early
bumper on tooth positions. Eur J Orthod. 2000 Feb; orthodontic treatment. J Am Dent Assoc. 1985
22(1):25-32. Nov;111(5):771-4.

11. Thüer U, Ingervall B. Pressure from the lips on the 17. Hashish DI, Mostafa YA. Effect of lip bumpers on
teeth and malocclusion. Am J Orthod Dentofacial mandibular arch dimensions. Am J Orthod Dentofacial
Orthop. 1986 Sep;90(3):234-42. Orthop. 2009 Jan;135(1):106-9. doi: 10.1016/j. ajodo.
2007.10.038.
12. Thüer U, Ingervall B. Effect of muscle exercise with
an oral screen on lip function. Eur J Orthod. 1990 18. Nevant CT, Buschang PH, Alexander RG, Steffen
May;12(2):198-208. JM. Lip bumper therapy for gaining arch length. Am J
Orthod Dentofacial Orthop. 1991 Oct;100(4):330-6.
13. Thüer U, Janson T, Ingervall B. Application in
children of a new method for the measurement of forces 19. Werner SP, Shivapuja PK, Harris EF. Skeletodental
from the lips on the teeth. Eur J Orthod. 1985 changes in the adolescent accruing from use of the lip
Feb;7(1):63-78. bumper. Angle Orthod. 1994;64(1):13-20; discussion
21-2.
14. Hodge JJ, Nanda RS, Ghosh J, Smith D. Forces
produced by lip bumpers on mandibular molars. Am J 20.Grossen J, Ingervall B. The effect of a lip bumper on
Orthod Dentofacial Orthop. 1997 Jun;111(6):613-22. lower dental arch dimensions and tooth positions. Eur J
Orthod. 1995 Apr;17(2):129-34.
15. Osborn WS, Nanda RS, Currier GF. Mandibular
arch perimeter changes with lip bumper treatment. Am
J Orthod Dentofacial Orthop. 1991 Jun;99(6):527-32.

…………………………

How to cite this article?

Ben Mohimd H, Benyahia H, Taleb B, Zaoui F. Management of space in the mixed dentition: The use of lip bumper. Int
J Pediatr Res.2016;3(6):440-445.doi:10.17511/ijpr.2016.i06.12.
………………………………………………………………………………………………………………………………

Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 445 | P a g e

You might also like